Negotiating Distance: “Presencing Work” in a Case of Remote Telenursing

Abstract

Telehealth services offer accessible care to distributed populations. However, it is not clear how the important caring intervention of “presence” can be enacted in distributed settings. Information Systems literature theorizes “presence” in distributed work as something to be created by technologies as a precondition for effective work to occur. Following an abductive research process, we compare extant conceptualizations of presence with an empirical case of telenursing. We find that in order to be a caring presence, telenurses must skillfully employ technology while drawing on past embodied experience, in order to balance the “dualities of distance” of nearness and farness; control and freedom. We thus recast presence as a form of skillful work with technology, not as an antecedent to, but a part of telenursing practice. Our model of “the dualities of distance in presencing work” prompts new understandings and offers new directions for future research in both HISR and IS.

Full text

Negotiating Distance: “Presencing Work” in Telenursing
Thirty Seventh International Conference on Information Systems, Dublin 2016 1
Negotiating Distance: “Presencing Work” in
a Case of Remote Telenursing
Completed Research Paper
Ella Hafermalz
The University of Sydney
H70, Abercrombie Building
NSW 2006 Australia
ella.hafermalz@sydney.edu.au
Kai Riemer
The University of Sydney
H70, Abercrombie Building
NSW 2006 Australia
kai.riemer@sydney.edu.au
Abstract
Telehealth services offer accessible care to distributed populations. However, it is not
clear how the important caring intervention of “presence” can be enacted in distributed
settings. Information Systems literature theorizes “presence” in distributed work as
something to be created by technologies as a precondition for effective work to occur.
Following an abductive research process, we compare extant conceptualizations of
presence with an empirical case of telenursing. We find that in order to be a caring
presence, telenurses must skillfully employ technology while drawing on past embodied
experience, in order to balance the “dualities of distance” of nearness and farness; control
and freedom. We thus recast presence as a form of skillful work with technology, not as
an antecedent to, but a part of telenursing practice. Our model of “the dualities of distance
in presencing work” prompts new understandings and offers new directions for future
research in both HISR and IS.
Keywords: Presence, Distributed Work, Telenursing, Remote Work, Abductive Research

Negotiating Distance: “Presencing Work” in Telenursing
Thirty Seventh International Conference on Information Systems, Dublin 2016 2
Introduction
Telehealth services are an efficient way of offering accessible care to a distributed population (Tuxbury,
2013). The practice of delivering nursing care either over the phone or through video conferencing is
referred to as “telenursing” (Hagan, Morin, & Lépine, 2000). An important question that arises in the shift
to telenursing is “how the physical separation related to telehealth use may affect the experience of presence
among nurses during nurse-patient interactions” (Tuxbury, 2013, p. 155, emphasis added). “Presence” is a
term used in both the nursing and Information Systems literature, however the word has a different
meaning in the two fields. In nursing theory, presence is a care intervention that is described as “being-
there-for and being-there-with” the patient, in a way that is healing and transformative for both nurse and
patient (Kleiman, 2009, p. 6). In Information Systems (IS) literature, presence, or “co-presence”, has been
defined as the “illusion of having access to a remote or distant other that shares the same distant place, that
is, being there with others” (Schultze, 2010, p. 438).
Now that nursing and other health services are being conducted remotely using Information
Communication Technologies (ICTs), we argue that it is worth considering what one field can learn from
the other about presence, and how the integration of healthcare with IS might benefit from a
reconceptualization of presence. In this paper we follow an abductive research process (Alvesson &
Sköldberg, 2009; Dubois & Gadde, 2002, 2014) to show that extant understandings of presence are not well
suited to helping us make sense of our empirical case of telenursing. As such, we problematize the notion
of presence in response to empirical material. With further insight gained from exploring alternative
philosophical groundings, we develop new a model that better accounts for what is involved in becoming a
caring presence for geographically distant patients. We here seek to “push the contextual envelope of IS
research” (Chiasson & Davidson, 2004, p. 175) by drawing on IS and nursing research simultaneously. We
develop a model of presencing work that will offer insights relevant to Health Information Systems
Research (HISR).
We begin by briefly summarizing prominent understandings of presence in both nursing and IS literature,
and demonstrate how the latter understanding is founded on a set of often taken-for-granted cognitivist,
Cartesian assumptions. We then outline our research approach and an empirical case where nurses work
from their homes, triaging patients solely over the phone, without video connections. In working with the
case material we follow an abductive research process (Alvesson & Sköldberg, 2009; Dubois & Gadde, 2014)
in which we iterate between theoretical and empirical material. This means that we will bring in new
conceptual material in order to respond to our initial, and surprising case findings. This iterative process
enables us to generate new insights about presence in telenursing, and our paper is organized accordingly.
Throughout the text we will provide case descriptions and quotes to illustrate our theorizing.
We find that the telenursing work in our case challenges the orthodox IS conceptualization of presence,
because 1) unlike the cognitivist way in which presence is conceived of in prominent IS literature, a nurse’s
experience and body are actively involved in creating technologically mediated presence and 2) that
presence in telenursing requires skillful use of technology but is not created by it. In responding to these
surprising findings, we draw more deeply on existential philosophy (Dreyfus, 2005; Dreyfus, 2002;
Merleau-Ponty, 1962), which has already been influential in humanist nursing theory (Doona, Haggerty, &
Chase, 1997), to create new opportunities for thinking about presence in the context of HISR.
As a result, we construct a conceptual model of presencing work as our main contribution to HISR
literature. The model conceptualizes presencing work as an active balancing of two dualities of distance,
which we present as nearness/farness and freedom/control. We argue that understanding presence in
terms of the work that goes into balancing these dimensions can deepen our appreciation of the skill and
work that goes into presence, and at the same time reveal presence not as an antecedent to but an integral
part of telenursing work itself. Conceptualizing presence as an activity opens up new opportunities for
future research. We further suggest that the model may be helpful in developing our appreciation of what
is required for remote healthcare services to effectively offer care to a distributed population using ICTs.
The Concept of Presence in Nursing and IS Literature
The term “presence” features in a range of different research fields. We here consider how the term has
been used in nursing, and then contrast this understanding with how presence has been theorized in IS

Negotiating Distance: “Presencing Work” in Telenursing
Thirty Seventh International Conference on Information Systems, Dublin 2016 3
literature. We find that while the term is relevant to both nursing and IS, it is used quite differently in these
two fields. We provide this background to open up the space for our research interest, which is to investigate
how the term presence might be best understood in the hybrid context of telenursing (which brings together
nursing and IS).
Presence in the nursing literature: a care intervention
The notion of presence in nursing is strongly related to the concept of “care” (Covington, 2003). Specifically,
nursing presence involves a process whereby the nurse develops a caring relationship with the patient
through attentiveness and availability (Covington, 2003, p. 311). Thus, nursing presence is seen “not [as]
the physical proximity of the nurse” but rather as a process that is “existential and essential”, because
presence is only possible when “the nurse is immersed as a unique individual in a unique moment in time
with another unique human being” (Doona et al., 1997, p. 13). This nursing understanding of presence is
rooted in existential literature and focuses on the way in which being with another person in a caring way
can positively affect their health and wellbeing (Doona et al., 1997).
The concept of presence is important to nursing practice, but it is intentionally treated with ambiguity, as a
quality that is recognizable but not necessarily fully describable. This is in part because there is resistance
to the very idea that presence can be standardized, measured, replicated, or even explicitly taught (Doona
et al., 1997; Turner & Stokes, 2006). While this concern is understandable, the ambiguity that surrounds
the concept makes it difficult for an outsider to appreciate the skill that is involved in nursing presence. It
is part of our study to contribute to a better understanding of the skillfulness of nursing presence.
Although nursing presence is not only about physical presence, the context in which it has been examined
and exercised has traditionally been co-located. Presence is nearly always discussed in the nursing literature
in the context of interaction with patients in a shared physical healthcare setting (Covington, 2003; Doona
et al., 1997; Owen-Mills, 1998). Telenursing therefore poses an interesting challenge for nursing theorists
and practitioners interested in the concept of presence. Given that telenursing exists at the intersection of
healthcare and IS, we now turn to IS literature that has theorized the notion of presence in the context of
distributed work. We offer a brief summary to show that in contrast to the nursing literature, IS theories of
presence are predominantly cognitivist and sometimes technologically deterministic.
Presence in information systems literature: an illusion caused by technology
In IS and related literature, such as Computer Supported Collaborative Work (CSCW), presence in ICT-
mediated communications is often said to happen when an “illusion” occurs. In this sense, presence
between distributed team members happens when technology’s role in bringing people together is
suppressed from sensory awareness, resulting in the “perceptual illusion of nonmediation” (Lee, 2004;
Lombard, 2000, p. 77). In such a conceptualization of presence, the mind is “tricked” into ignoring the
physical realities of the body’s “actual” place, as opposed to its perceived (but not “real”) position in the
virtual. The implicit assumption here is, we argue, that technology can create an illusion in which the
“virtual” and the “real” are confused by the mind, so that a person can be made to experience a simulated
or “virtual” situation as if they were there.
The aim here is for technology to connect people but for its role not to be noticed. As a result, this strand of
literature on technologically mediated presence tends to focus on how technologies and routines can be
designed and implemented to create presence. For example, in a recent study on ubiquitous video
conferencing arrangements at Google, the authors describe these technological configurations (“portals”)
as being able to “provide presence and status information on par with being co-located” (Karis, Wildman,
& Mané, 2016, pp. 47, emphasis added ). Here, technology is regarded as being the enabler or even creator
of presence. Further, the gold standard against which this technology is assessed is always physical co-
location. This somewhat deterministic premise is echoed in Computer Supported Collaborative Work
(CSCW) and design literature, where technologies are designed to “create” presence (for a critique see
Riemer, Klein, & Frößler, 2007). For example, “virtual presence” has been defined as “presence caused by
virtual reality technologies” (Lee, 2004, pp. 29, emphasis added; Sheridan, 1992, 1995).
The above understanding of presence in IS can thus be broadly associated with a cognitivist orientation.
The term “telepresence” for example was coined in 1980 by cognitive scientist Marvin Minsky to highlight
“the possibility that human operators could feel the sense of being physically transported to a remote space

Negotiating Distance: “Presencing Work” in Telenursing
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via teleoperating systems” (Lee, 2004, p. 28). The concept of telepresence has since been defined as “a
feeling of being in a location other than where you actually are” (Lee, 2004, p. 28), and as the “suspension
of disbelief that they [users of virtual reality systems] are in a world other than where their real bodies are
located” (Slater & Usoh, 1993, p. 222). These descriptions demonstrate a cognitivist orientation because
they position presence as something that is experienced in the mind of a perceiving subject. Cognitivist
science, which we argue has been influential in the distributed work literature’s understanding of presence,
strongly reflects a Cartesian worldview (Gardner, 1985 in Riemer and Johnston, 2014). Riemer and
Johnston (2014) further point out that the Cartesian worldview underpins much of IS research. We now
consider how this ontological grounding informs assumptions about presence in prominent IS literature.
Grounded in the philosophy of René Descartes, Cartesianism has become a powerful folk ontology that
underpins much of Western thought since the enlightenment (Riemer & Johnston, 2014). In Cartesianism,
the mind and body are “entirely different” (Harman, 2009, p. 35). The body is seen as a container that
carries the mind. On this notion, technology thus holds the promise of freeing the mind from the shackles
of the body, a metaphor that comes to the fore in explicit utopian fantasies of “uploading the mind”
(Hauskeller, 2012). Cartesianism further relies on the assumption that it is possible to consider the world
objectively, as if from nowhere. This disembodied theoretical stance relates strongly to a conceptualization
of space as a homogenous measurable expanse in which the shape and size of bodies, and their locations,
can be plotted as geographic coordinates (Malpas, 2006, p. 71). Under this dominant view, there is only one
objective space in which all phenomena occur, and the space between two bodies can be measured as
objective distance.
This Cartesian worldview informs a popular conceptualization of ICTs as “disembedding mechanisms”
(Giddens, 1990). ICTs can in this view “dissociate the place of interactions (as well as tasks) from space and
time” (Majchrzak & Malhotra, 2013, p. 2). ICTs can therefore facilitate relations between “absent” others
(Majchrzak & Malhotra, 2013, p. 2). This understanding of ICTs as separating “social relations from (local)
same-place same-time contexts” underpins much of the extant virtual collaboration scholarship (Majchrzak
& Malhotra, 2013, p. 2) as well as conceptualizations of presence in IS. Viewing technology as a
“disembedding mechanism” perpetuates a sense that technology enforces or facilitates a separation
between where the body “is” and where the mind “is”, creating an analytic spit that artificially de-
emphasizes the role of the body’s involvement in time and space, as well as what this involvement means
for presence.
We have presented a brief overview of prominent IS literature on presence here, and recognize that there
are other works that explore the concept with more nuance, for example from a practice perspective (Riemer
et al., 2007). Schultze (2010) provides an overview and definitions of terms that are related to presence,
such as co-presence and social presence. In these definitions however, technology is still treated as the key
factor in creating presence as a condition for interaction, and presence in distributed contexts is still
predominantly discussed in the context of an illusion that conceals a split between mind and body. In
reflecting on the contrast between the nursing literature’s conceptualization of presence as an interpersonal
caring intervention, and the selected IS literature’s conceptualization of presence as an illusion created by
technology, we come to see that the two fields are not so easily brought together. In order to move past this
apparent conceptual incompatibility, we will turn to an empirical example to see what we can learn from a
case of telenursing. We do so in what is known as an “abductive” research process, which we now explain.
Research Approach
In the following we explain the non-linear approach (Dubois & Gadde, 2002, 2014) to case study research
that we have taken in order to develop a new understanding of presence that caters to the emerging research
context of telenursing. We first show that are our research aim has been to “problematize presence”, by
which we mean we have aimed to uncover the dominant assumptions that underpin common
understandings of presence, with the view to rebuild a conceptualization of presence that is better suited to
understanding findings from our empirical case and the wider research context of telenursing. We then
explain how this problematization has been achieved through an abductive case study research process
(Timmermans & Tavory, 2012), which has involved iterating between empirical and theoretical material
(Alvesson & Kärreman, 2007) as we responded to surprising findings from the case and generated new
insights subsequently. Finally, we introduce our case setting and provide background information for
understanding the case context.

Negotiating Distance: “Presencing Work” in Telenursing
Thirty Seventh International Conference on Information Systems, Dublin 2016 5
Problematizing “presence”
We have briefly shown that presence is an important concept in both nursing and IS literature, but that
each field views this concept differently, according to dominant assumptions, as informed by deeper
philosophical orientations and practical concerns. In this paper we problematize (Alvesson & Sandberg,
2011) the concept of presence by turning to an empirical example of telenursing. Telenursing is a significant
empirical context here, because the practice of nursing over the phone is challenging to both the nursing
literature’s understanding of presence, as grounded in (though not synonymous with) physical interaction;
and the IS understanding of presence, as an illusion that is created when technology conceals a separation
of mind and body.
Problematization aims to interrogate one’s own assumptions and those of the extant literature (Alvesson &
Sandberg, 2011). This approach eschews “gap spotting”, because identifying and filling a gap in existing
literature and/or knowledge does not encourage a critique and constructive re-imagining of existing
assumptions and trajectories. This strategy is therefore well suited to the research topic of how presence
figures in the practice of telenursing, because, as we have shown, the current literatures are not forthcoming
with a coherent way for understanding presence in the hybrid world of telenursing.
In keeping with how Alvesson and Sandberg (2011) employ problematization, we go beyond a mere critique
of current conceptualizations of presence. We use an empirical case of telenursing first to prompt a
deconstruction of current understandings of presence by reading our empirical observations through this
prior understanding obtained, and then proceed with the constructive work of building a conceptual model
inspired by what we have learned from our case and our engagement with additional theoretical material.
In this way, problematization is used to both break down current understanding and build up new
understanding, which we in turn argue might be useful for others in their investigations of telenursing and
other forms of distributed caring work. The method we employ to mobilize our problematization of the
concept of presence is called “abductive case study research”.
Method: abductive case study research
Abductive research is an alternative approach that we argue is suited to this study’s aim of problematizing
current understandings of presence, in a way that will offer insight and constructive theorizing for the HISR
field. In the following quote, Alvesson and Sköldberg (2009, p. 4) offer a summary of the abductive research
approach that we have followed in this paper:
Abduction starts from an empirical basis, just like induction, but does not reject theoretical
preconceptions and is in that respect closer to deduction. The analysis of the empirical fact(s) may
very well be combined with, or preceded by, studies of previous theory in the literature; not as a
mechanical application on single cases but as a source of inspiration for the discovery of patterns that
bring understanding. The research process, therefore, alternates between (previous) theory and
empirical facts whereby both are successively reinterpreted in the light of each other.
Abductive research thereby acknowledges and celebrates the inter-relationship between understanding,
reality, and theory. This approach does not try to conceal the constructed nature of knowledge, and the
researcher is recognized as having an active role in the way in which they place empirical and theoretical
material in critical dialogue (Alvesson & Sköldberg, 2009).
Rigor is pursued in abductive research through a reflexive process wherein both empirical and theoretical
material are held accountable to one another, while relevance is defined by whether insights are formed
that are of interest to the wider research and practitioner community (Alvesson & Sköldberg, 2009).
“Empirical material” is thus seen as a critical “dialogue partner” (Alvesson & Kärreman, 2007) in the
process of critical reflection. Empirical material, which is here generated through interviews, inspires us to
provoke commonly held understandings and thereby helps us to develop critical, interesting, and relevant
theoretical interpretations which we bring together in a conceptual model of presencing work. True to our
abductive approach, we will weave in theoretical material as it becomes relevant, in response to the
surprises that emerged from our empirical work.

Negotiating Distance: “Presencing Work” in Telenursing
Thirty Seventh International Conference on Information Systems, Dublin 2016 6
The abductive research process (Alvesson & Sköldberg, 2009; Dubois & Gadde, 2014) is iterative in that
what is interesting about the empirical setting emerges and is refined through careful reading and reflexive
reasoning, while drawing on theoretical material. Our abductive process proceeds in three steps: 1) We
derive findings from our case setting that present as surprising or problematic when read against prior
understanding provided by the literature; 2) we then provide a response to these findings by reaching for
alternative theoretical material, which allows us to 3) derive new insights from this dialogue between the
empirical and the theoretical material. In what follows, the structure of the paper resembles this three-step
process and results in a model of presencing work as our main contribution, derived from this abductive
process.
Case setting
We draw on an illustrative case study from the Australian healthcare sector. HealthOrg is a pseudonym for
a large Australian health services organization, which is contracted by the Australian government to provide
a telenursing service to the general public. Registered nurses are employed to work from their homes. They
answer calls from the public, who describe their own or their charge’s medical issue verbally. The nurse
uses a range of technology in guiding the patient through a triage process over the phone, at the conclusion
of which the patient is advised on the appropriate action to take: stay at home, see a doctor, or go to hospital.
The government funds this contracted service in order to reduce pressure on emergency wards and thereby
reduce emergency room waiting times. The nurses triage patients by drawing on their clinical training, with
the assistance of an algorithmic Decision Support System (DSS). A call is referred to as an “encounter”. At
the conclusion of the encounter, a “disposition” is reached by the DSS, which advises patients to either
monitor their medical situation, see a doctor, or attend an emergency department. In some encounters the
nurse will override the disposition reached by the DSS. The nurse can also arrange an ambulance or refer
the patient to other services.
Over 300 nurses work on this service from their homes using a computer, telenursing software, and headset
provided by the organization. We interviewed both nurses and leaders at HealthOrg; twelve in total and
some of these more than once. All except one interview were conducted over the phone. One of the
researchers was also given a demonstration of the software system and listened in on a recorded de-
identified call. This empirical material was then iteratively analyzed as part of the abductive process.
Initial Findings: Presence as Embodied Activity with Technology
We show in this section what we learned from our initial engagement with the case material and what was
surprising to us. In particular, we were struck by how the nurses discussed their interactions with patients
and their use of technology. We found that becoming present with a patient required a skillful process of
communication and visualization, where the nurse drew on her
1
past experiences of nursing in a hospital
and on her own embodied understanding for making sense of the encounter. We also learned about how
technology was involved in this effort to become present, but that the technologies involved did not by
themselves create presence. In doing so it became clear that the same caring presence could not have been
created by a layperson using the same mix of technologies as a nurse.
The primary focus of the nurses’ work is on triaging patients over the phone. Calls are allocated via a central
system and a nurse will see basic details of the call they are about to take. On screen they will see where the
person is calling from and will receive a whisper in their headset, which lets them know what greeting they
should use, as each State and Territory has a different name for the service. The nurse then needs to balance
getting basic contact details from the caller with making a quick initial assessment of what kind of situation
is at hand – is this an emergency, or is there time to discuss the patient’s condition? Once an initial clinical
assessment is made, the nurse will open the relevant “guidelines” on their computer system and will follow
a series of questions prompted by the algorithmic DSS. Though some patients expect it, the nurses are not
permitted to diagnose the medical condition. The aim of the call is to quickly and safely triage the patient.
The following section presents what we learned from speaking with nurses about their work.
1
In the case, all the nurses interviewed were female, and so we use feminine pronouns throughout.

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When interviewing the nurses, we were firstly interested in learning about their work practices – what the
role involves and how the nurses cope with working from home. We found that for the most part the physical
distance between nurse and patient was not a problem for the nurses, as they were in most instances
satisfied with the way in which they could handle patients’ issues over the phone. Several nurses in fact
reported that the physical distance from patients was a part of what attracted them to the job, having been
physically assaulted at some stage in their clinical nursing careers. These nurses did not miss the dangers
and taxing physical demands of the emergency ward. Some nurses had injuries or disabilities (examples
were back injuries, and PTSD, associated with nursing work). Others had caring responsibilities that were
incompatible with the varied rosters of standard hospital nursing shifts. For these workers, the opportunity
to nurse while sitting down in a comfortable and safe home environment was highly desirable and in some
cases was the only way in which they could continue to practice nursing.
Becoming present requires work that draws on past, bodily experience
The first surprising finding was the degree to which nurses reported working hard in their efforts to get a
sense of the patient, in order to “see” the “full clinical picture”, and to ultimately become a caring presence
with and for the patient. This work was described in terms such as “visualizing” and “thinking on your feet”.
We find that building a “full clinical picture” of the patient and the encounter required skillful work that
drew on past nursing experience. The point we take away from this is that while nurses are no doubt
reflecting on what they hear, they primarily draw on bodily sensations and a shared understanding of what
it is like to be in a nursing situation in an embodied way, in coming to a reflective assessment of the
encounter. We explore this finding further in the following illustrations.
One of the challenges involved in this form of telenursing is seeing the patient’s condition using only
telephone equipment, a computer, and the algorithmic DSS. Nurses reported drawing heavily on past
experiences of working in emergency rooms to help them to quickly “visualize” what they were
encountering:
…you've got to visualize straight away, is this an old person who's struggling who can't even talk to me
or is it a younger person who's generally in good health but this is a short-term problem? So every
question you ask you've got to be visualizing what might be happening. You draw on your own
experience as you're always visualizing in your own head. I've seen this before. This sounds like. This
feels like. Then with it - with that thinking, you then go into one of the algorithms and start going
through a process of set questions. But in that initial assessment you've got to be visualizing what
could be happening. That is vital. You're thinking on your feet.
While this description could be taken to reinforce the idea that presence takes place “in the mind”, we locate
here evidence for breaking down a conceptual mind/body division. This nurse is describing drawing on
experience in an embodied way to reflect on and visualize what is happening, all the time “thinking on her
feet”. This practice of visualizing the caller’s environment seemed to be a skill that was learned over time
and was usually linked to an experience the nurse had had, either in a hospital or in their daily life. In each
description, the nurse’s body was very much involved in understanding what she was dealing with: “I’ve
seen this before. This sounds like. This feels like.” Her experiences attending to bodies and her own senses
and bodily memories fundamentally guided the triage process.
Mostly, the patient’s condition could be grasped through this process of nurse and computer working
together to ascertain the best course of action. At times however it was harder to “see” what was happening,
particularly when patients were suspected to be “making up” the situation they were reporting. Here, one
nurse reported becoming uneasy, registering that something wasn’t “right”. In such instances, the nurses
reportedly relied on their “gut” instincts as well as their official procedures and guidelines in responding to
the incompleteness or unintelligibility of the situation. One story came from a nurse who described a
troubling situation with a reportedly suicidal caller:
I can't see what she was doing. What did she do? She rung up and she said, “I'm going to kill myself.”
Generally, somebody who says that are not, probably wouldn’t. It doesn't usually come up. I don't
know, you just know. “I'm going to jump in front of a truck. I'm on the freeway…” and I could hear

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Thirty Seventh International Conference on Information Systems, Dublin 2016 8
lots of traffic in the background. “I'm going to throw myself in front of a truck.” Then she put the
phone down, still on, I'm still connected, and 10 minutes later it was still there.
This scenario was very difficult for the nurse to cope with. She could hear the road and felt she was with the
caller yet could not intervene or trust what she was being told – she could not get a grip on the situation in
order to direct it. Only a lack of “brakes screeching” and her background understanding that came from
experiencing similar calls indicated that the caller may have been misleading the nurse. The nurse here
needed to draw on her implicit sense of what was going on in her efforts to be a caring presence for the
troubled caller.
There are procedures in place for reporting and debriefing after such instances, and sometimes a call can
be traced and emergency services dispatched. Once the line is disconnected however, little can be done to
follow up on the patient, and the nurse will likely need to move on to their next caller. This example is
however the exception. In everyday encounters, the nurses are expected to be able to make sense of the
situation quickly in order to direct the course of action. The nurse has to quickly and calmly grasp what is
relevant in forming an understanding of the situation, which again is part of forming the “full clinical
picture” which allows appropriately advising the patient.
We followed up by asking the nurses whether it would be easier if patients were able to send through
photographs of their ailments. Patients reportedly did at times want to send through a photograph – for
example of a rash - to help the triage process. This was however not desired by the nurses. This is firstly
because it would take more time as it is more complex from a technical perspective. Secondly, part of the
appeal of the phone line is that most people in Australia have access to a telephone, though not everyone
(the elderly for example) would have access to the technology or the skills necessary to transmit a
photograph or video. Thirdly, images could be misleading without a sense of context, and so skillful
questioning was seen as more effective. One nurse for example explained that a picture of a wound could
“look really bad, and really huge” in a picture, depending on how the picture was taken. In this example of
a wound, getting a “full clinical picture” was reportedly not helped by visual representations. This challenges
a popular notion that an image offers more (and therefore better) information. Without a sense of
proportion, a rash could appear far worse than it was – an image would therefore not allow for the context
that would be necessary to render the situation intelligible to the nurse.
Moreover, one of the researchers heard on a recorded call an example of how the nurses were able to gain
a sense of proportion, by using everyday experiences and common frames of reference. While the algorithm
might have prompted the question “how large was the swallowed item?” a skilled nurse instead asked “was
the bead about the size of a ten cent piece?” This translation from generic language to a relatable everyday
(Australian) object helped the patient quickly provide the relevant information and made it possible for the
nurse to connect with the patient and become a caring presence for them. Another nurse explained how she
used this linguistic device – referring to common frames of reference – in her triaging practice. She
explained that she would ask:
“…does it look extremely red like a tomato or is it mildly pink?” “So do you think it's wider than say a
two-inch or five centimetre diameter, or is it just about the size of your fingernail on your little finger?”
…you just work around - you find things that most of us have that we can share and identify, “yeah,
it's about the size of your little fingernail” …so you can get pictures that way, which is really not such
a big difference [to receiving a photograph].
In this way, carefully guided descriptions of everyday items and bodily frames of reference were considered
sufficient and often preferable for getting “pictures” that facilitated the triage process. The nurses became
skilled in seeing in this way and commented that photographs and video would cause more problems than
they would solve – by distorting the situation, creating privacy issues, or increasing the complexity and time
taken to get a handle on the patient’s condition.
In conclusion, we would like to draw attention here to the strong role that the body plays in these
encounters. In getting closer to the patient, the nurses were drawing on what was common to both patient
and nurse: an embodied understanding of a common world. This background understanding, when
skillfully articulated and drawn upon, provided a bridge between the nurse and patients’ phys ical contexts
and made it possible for the nurse to be a caring presence for the patient. In doing this skillfully, nurses

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relied on clinical hospital experience as well as previous experiences of calls. Although the DSS in many
ways provided the script for the encounter, the nurses reported constantly translating the system’s prompts
into language that was appropriate and relatable for the person they were interacting with. In other words,
the algorithm could not have been a caring presence for the patient without the nurse, a point that we now
explore with further details from the case.
Distributed presence requires technology but is not created by it
We acknowledge that without technology, the nurse and patient could not interact. Often geographically
located on opposite sides of a vast country, one of the appeals of this service is that even those who live in
very remote locations can have access to healthcare advice with the use of basic technology (a phone). We
quickly learned however that the technologies involved in telenursing were not used in a standardized or
straightforward way. By this we mean that the nurses reported taking time to adjust to the systems they
were using and that they had to learn how to use the technology in building a connection with patients.
Before this skill was learned, the DSS in particular could get in the way of their attempts to become present
with their patients. This was mainly because the systems in place were aimed at increasing the efficiency of
calls, an imperative that at times could conflict with the nurse’s efforts to care for and be with their patient
in a caring way. We acknowledge that this conflict between efficiency versus care, which is often associated
with the construct of technology versus care, is a familiar story in many healthcare contexts (Mol, 2008).
The unique technological setting of telenursing took some getting used to for the nurses. Adding to the
stress of the role was the constant pressure to reduce “call times”, which are a Key Performance Indicator
(KPI) for the nurses, as the company’s call time average is tied to the continuation of the contract between
HealthOrg and the government. The target call time is set at approximately nine minutes. This restriction
was seen as often being in conflict with the imperative to care for the patient, and nurses reported struggling
with the two competing agendas – to complete the call quickly and safely, and to “be there” for lonely and
troubled patients. Some nurses focused more on efficiency, and particularly on the “call control” required
to achieve this. “Call control” was a phrase used to refer to a way of speaking to callers that at once reassured
them while facilitating a fast and accurate assessment of their situation.
Even though the algorithmic system that accompanies the triaging process is designed to minimize call
times, it could reportedly slow down the call initially and get in the way of nurse’s efforts to care for their
patients. Over time however, nurses reported learning to work more harmoniously with the system and
their call times began to improve:
…when you first start, your call times are quite high because you're still finding your way around the
software, you've got to find all the health information for people and you're scared because you can't
see the patient, so you cover everything. Then as you progress through in time, your calls become
much, much quicker. Now, I do a call half as fast as I did when I first started… I think a lot of it is to do
with trusting the guideline that you're using because it will cover everything.
This notion of “trusting the guideline” came up in various guises. The algorithmic DSS, which offers a
number of different decision-tree “guidelines” based on the suspected condition, was often treated as
somewhat of a colleague. Nurses said that it was best to trust that the right path would unfold according to
the decision-tree. This did not however mean that the nurse merely read out the prompts, rather, they
learned to work with and around the system as necessary. When nurse and system worked well together,
the call was reportedly conducted more quickly and more safely than if the nurses were to work in isolation.
In this way, technology could, with practice, support the nurse’s efforts to become a caring presence with
the patient.
We find therefore that in becoming present with a patient, it was necessary for the nurse, computer, headset
and software to work together, with more or less ease, in their collective effort to care for the patient. There
was a similar sentiment of seamlessness regarding the headset that is worn while on a shift – we asked a
nurse if it seemed like part of her uniform, to which she replied:
Yeah, the headset definitely helps. Although, I don't notice it after a while - unless my ear starts to go
dead.

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A sense that the technology could be a barrier to care, or a part of caring practice, emerged upon careful
analysis of the interview transcripts. Technology was only really mentioned explicitly in terms of how it
became a problem, such as when the headset put pressure on a nurse’s ear. In most instances, the nurses
had learned to “get on” with the tools and systems they were involved with and over time became skilled in
knowing when to let the system “speak” and when to override it or work around it.
A consideration of balancing care and efficiency was persistently in play in the nurses’ reflections. Both
technological proficiency and clinical experience were considered important. New recruits described
struggling with the “call control” necessary to balance efficiency and care. The nurse needed to be in control
of the flow of information, so that what was relevant in coming to terms with the situation was prioritized.
Overall it seemed that the nurses came to understand what was needed to care for each patient in the way
that was best for them. When executed skillfully and successfully, these encounters would result in the nurse
being present with the patient in a caring way.
We will now reflect on these findings in relation to the extant literature on presence in IS. This leads us to
consider how an alternative conceptual approach that draws on existentialist literature can help us to make
sense of our findings and guide new understandings and promising research directions.
Response: Reconceptualizing Presence
We note that the findings presented above raise problems for the orthodox view of presence in IS. Firstly,
we have explained that presence in the IS literature has often been defined as an illusion, created by
technology, which needs to also cover over its role in splitting mind and body. In our case however, we
found that nurses draw on their past experiences and an embodied understanding of the world in their
efforts to connect with and become present with patients. Though they do reflect on what they are feeling,
and often make their “gut” feelings explicit, getting a “full clinical picture” of the encounter would not be
possible without drawing on the embodied experience of being a nurse. The nurses draw heavily on their
bodily experience coping with past situations in their nursing careers, to make sense of and act upon the
bodies of their patients, for example by listening to breathing and in asking the patient to sit down using an
assertive voice. These encounters are not easily reduced to mental representations or cognitive
computations, rather the body is involved in different ways in how the nurses become present with their
patients.
Secondly, the technology involved in calls is quite simple (unlike for example some of the virtual reality
devices discussed in some presence literature), yet there still seems to be a capacity to be present with a
patient using this equipment, when it is adopted into nursing and caring practice. We recognize here that
the technology is necessary for the nurse to be able to become present with the patient, but that this
technology is not sufficient for establishing presence. For example, if the phone, headset, computer and
DSS guidelines were in the hands of an ordinary member of the public, the same kind of presence would
clearly not be possible. Therefore, presence in the case cannot be understood as the result of technological
features. Moreover, we suggest that there are likely different modes of presence, which are experienced in
qualitatively different ways.
Finally, presence is sometimes positioned in CSCW literature in particular as being a starting point from
which work tasks can proceed: something to be ascertained a priori (Ishii & Watanabe, 2009; Karis et al.,
2016). The case however demonstrates that presence is brought about in and through the nurses’ work, it
is a part of it rather than a precursor to it. Because these points run contrary to dominant understandings
of presence in IS, but are also quite new to the nursing context, our case findings thus prompt a
reinvestigation more fundamentally of what it means to become present with another in the context of
remote healthcare.
In the following, we continue with our problematization of the concept of presence by drawing on an
alternative philosophical grounding: existentialism. We are drawn to this body of literature because, as we
have already explained, nursing theory and practice has previously drawn inspiration from existentialist
understandings of presence. We will then explore this conceptual basis further, and integrate what we have
learned from the case and this theoretical material in order to build a new conceptual model that
communicates our key insights to HISR.

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Towards an existential understanding of presence for HISR theorizing
In seeking theoretical material to assist us in making sense of how presence shows up in the case, we found
two related streams of relevant literature that are largely ignored in technologically-oriented and cognitivist
theories of presence. These streams are existentialist philosophy and holistic nursing. As the latter is
strongly influenced by the former, we focus here on how existentialist philosophers, specifically Marcel
(1965) and Merleau-Ponty (1962), have dealt with issues relating to presence and thereby develop an
alternative conceptualization of presence that we argue is helpful for future theorizing, both in HISR and
distributed work research.
The kind of presence that we are concerned with here involves care. The term “care” has a diversity of
meanings and philosophical connotations, particularly in Heideggerian language (Covington, 2003;
Heidegger, 1927; 1962). While some of these connotations may be welcome, we specifically use caring
presence here to mean a mode of being-with-others in a supportive way. This is most pronounced in and
more obviously needed in asymmetrical relationships, such as nurse/patient or mentor/mentee, however,
as a way of being involved with another, it is a feature of most if not all relationships and interactions.
For Marcel (1965) presence is strongly linked to the notion of involvement. He influenced nursing theory
by arguing that presence does not imply a mere physical connection, rather it is a kind of being-with that is
transformative for those involved (Marcel, 1965). In particular, Marcel (1965) dismisses the idea that
physical proximity equates to presence. Marcel counters the notion that proximity is synonymous with
presence by pointing out that we can experience farness with co-located others, to the extent that the
interaction can feel foreign and “unreal”. Conversely, someone who is geographically distant can come to
feel near because of one’s concern for and involvement with them.
This line of theorizing opens up a problematization of how distance itself is understood. Distance is
commonly understood in research and practice based on the model of Cartesian space, as a measurable
expanse between two coordinates. However, what is near in existential philosophy is understood in terms
of what is being attended to, that is, what matters to a particular person (Heidegger, 1927; 1962, p. 140).
Involvement with another is in this understanding therefore crucial to the notion of presence. This is
because caring presence is seen as being relational – it depends on a connection that is transformative for
those involved.
Marcel (1965) further points out that presence cannot be taught. While it is possible to teach the behaviors
associated with presence this is not the same as teaching the skill of presence itself:
…it would be quite chimerical to hope to instruct somebody in the art of making his presence felt: the
most one could do would be to suggest that he drew attention to himself by making funny
faces…teaching people to make their presence felt, is the very height of absurdity.
From this existentialist understanding of presence as skillful involvement, we can learn that presence has
been conceptualized as a relational achievement that is not concerned primarily with geographical distance.
Instead, phenomenal distance, meaning how distance is understood in terms of nearness and farness for
an involved being, needs to be negotiated rather than covered over (Heidegger, 1927; 1962) in coming to
be involved with another in an encounter.
Embodiment and the role of the body in presence
In existentialist philosophy, the world is always understood from somewhere, some vantage point, and it is
the body that is seen as fundamental to how we come to understand and act in the world (Dreyfus, 2002;
Merleau-Ponty, 1962). Past experience is therefore not an amalgamation of mental representations but
rather a combination of meaning and sense that is understood in an embodied way. Similarly, experience
itself is in this understanding the “intuitive coherence things have for us when we find them and cope with
them in our practical circumstances” (Carman, 2012, p. 10), and not merely a mental event.

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The crucial contribution here is that perception is fundamentally grounded in a bodily habitation in the
world and therefore:
To perceive is not to have inner mental states, but to be familiar with, deal with, and find our way
around in an environment. Perceiving means having a body, which in turn means inhabiting a world.
Intentional attitudes are not mere bundles of sensorimotor capacities, but modes of existence…By
manifesting in our bodily capacities and dispositions, perception grounds the basic forms of all human
experience and understanding, namely perspectival orientation and figure/ground contrast, focus and
horizon. (Carman, 2012, p. 10)
This theoretical grounding demonstrates how we can move away from an understanding of the “objective”
body that is locatable in geographic space towards an appreciation of the “phenomenal body” (Merleau-
Ponty, 1962) as the fundamental way of being involved in the world, in terms of which the world makes
sense. From this understanding of the phenomenal body, it becomes clearer that by focusing on where the
mind is and where the body is in accounts of presence, we miss a central consideration of the embodied
work that goes into becoming present in a situation in a skillful and involved way.
We have already pointed out that while presence is skillful, it cannot be explicitly taught, because to turn it
into a set of procedures would negate the importance of attending to the unique situation that is unfolding
between those who are involved in defining it. This is why presence is considered an important care
intervention in nursing yet nursing scholars and professionals resist the idea that it can be codified (Doane,
2008; Nelms, 1996). Particularly objectionable is the instrumental notion that presence can be done to
someone (Doona et al., 1997). Instead, presence is understood here as an embodied skill that depends on 1)
past experience in negotiating similar situations, and 2) a genuine involvement in and concern towards the
person and situation.
In beginning with an appreciation of involvement, the notion of presence as something that is worked at
and experienced in terms of past experience and embodied skill becomes possible. A reconceptualization
of presence becomes possible when we put aside the conventional understanding of distance as the gap
between two geographic coordinates in Cartesian space. Instead, we can consider distance as a phenomenal
quality that is negotiated in our involvements with the world. In comparison to the dualist understandings
of presence as being mediated by technology, which creates an illusion of a split between mind and body,
an existential understanding puts such distinctions to one side and concentrates on involvement: how a
situation is brought into focus against the background of what matters to a phenomenal body. From such a
grounding it is possible to appreciate how presence as an involved process of skillful performance is enacted
with technological equipment.
Insight: The Dualities of Distance
In our telenursing case we found that distance does not show up as a matter of kilometers. Rather, nearness
and farness are negotiated in order to build a connection with the patient, whereby presence between the
patient and the nurse is achieved. We found that this required the nurse to be skilled in both her experience
of nursing and in her use of technology. We here introduce the term presencing work to argue that presence
is not like a switch that can be flicked: it is not constant, guaranteed, or determined by technology. Rather,
presence requires careful involvement, experience, equipment, and ongoing skillful work.
This means that presence and work are not separate, and that presence is not a pre-condition for effective
collaboration. Rather, caring presence is an integral part of skillful work that needs to be continuously
balanced and maintained. When we consider the ongoing balancing work that goes into becoming present
with another person in a caring way, it is also possible to appreciate that presence is not a homogeneous
concept: different kinds or modes of presence are possible. In the following we discuss our
conceptualization of these modes and explore the negotiations that are involved in presencing work in both
practical and conceptual terms.
We do not claim to generalize the specific activities that are involved here, rather we draw attention to the
skillful nature of presencing work and argue that this cannot be programmed because it depends on 1) a
negotiation of near and far that involves equipment to bring this particular situation into focus, and 2)
control over the flow of information in terms of what is relevant to those involved. It is the balancing of

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these relational negotiations that we argue is important to a caring presence in distributed healthcare
environments. We now introduce the work of presencing as a skillful balancing of two dualities of distance.
These are nearness and farness and freedom and control.
Nearness and Farness
We have shown that the nurses draw on their past experience in helping them to build a connection with
their patients. Important here is how the nurse brings the patient closer through an enactment of familiarity
and intimacy. For example, one nurse described an encounter with a patient who had been in a farm
accident. She immediately perceived the sounds of a farm based on her own background understanding,
and thus was able to respond to the problem of windy background noise by anticipating the existence of a
Utility Vehicle (Ute) that could act as a wind buffer to improve the quality of the call. Her familiarity with
the patient’s context transpired in an empathetic stance towards the patient, where she directed the
situation in a way that established a nearness with him, to at the same time care for him.
Even though he is geographically distant, the nurse is with the patient in such a scenario, because she has
through skillful embodied performance brought the patient nearer, so that she can be a caring presence for
him. As with focusing a microscope or when conversing with another person however, closer is not always
better. An appropriate stance for involvement requires a certain farness as well – for example, we step
backwards if somebody stands too close; we release the pressure on the pedal if the car goes too fast.
Similarly, as much as the nurses described working to bring about a familiar closeness with their patients,
they were also involved in balancing this intimacy and nearness with a sense of separation and farness, in
order to achieve an appropriate stance from which to have the best grasp of the situation.
In a hospital setting, the nurse’s uniform is one way in which a sense of separation, or farness, is created
and maintained. A nurse recalled that when one puts on a uniform, an important separation is instated
between nurse and patient. As one nurse told us, a uniform “is a buffer between who you are and what job
you're doing - what you need to do. You're not going to be crying in the corner - in scrubs.” In a hospital, a
nurse touches bodies in a way that would not be appropriate in an ordinary setting, and so the uniform
creates the farness necessary for both patient and nurse to cope with such intimacy. Creating separation
helps the nurse to focus on the situation in a suitable way for the overarching purpose of becoming a caring
presence.
In the telenursing environment, this need for separation has to be negotiated differently. Creating a sense
of separation was important for the nurses, especially for avoiding questions about their own lives and
personal circumstances. The nurses discussed cultivating their “phone voice” to better negotiate the
balancing of the intimacy of their calls with a separation that was necessary for the call to be effective and
for the nurse to feel comfortable as well:
I do, definitely, have a phone voice that I use. So I think that is another separation…the same as if you
are nursing someone in hospital. You don't just, like, stand there with your shoulders hunche d and
say, “oh…” – while they're just talking at you…You kind of need to assert your presence and look
interested and really be available…
The way in which nurses “asserted” their presence with their callers and patients was frequently discussed
with such reference to bodily metaphors – “standing one’s ground”, “putting a hand on a shoulder”, “being
there” for and with a patient. What is second nature in the hospital environment – using the body and
equipment to signal both intimacy and separation – is here translated by the nurses in a skillful way into a
remote healthcare environment.
In sum, we argue that becoming present in this way requires a balancing of nearness and farness. Past
experience informs how the situation shows up while the negotiation of intimacy (nearness) and separation
(farness) is important for maintaining the appropriate stance from which the nurse can become a caring
presence for the patient, in the best possible way.

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Freedom and Control
Whereas negotiating of intimacy and separation in the balance of nearness and farness pertains to the
comportment towards the patient as such, the second dimension of balancing distance refers to how the
nurses “take control of the situation” for the duration of the call, in coming to grasp the “full picture” of the
encounter. By this we mean that the nurse needs to both control what is disclosed while also giving the
patient freedom to express what is important to them. A balance of both control and freedom are required
for the nurse to become present with the patient in a caring way.
While controlling another person can go too far, being a caring presence usually requires one party taking
some responsibility for another. To take an example from nursing in a hospital, giving a long-term patient
the choice of whether or not to get out of bed in the morning can actually be understood as uncaring and
even neglectful, because part of a nurse’s role is to take responsibility for the patient (Mol, 2008). In order
to be a caring presence with and for the patient then, a degree of control is necessary . However, unlike in
some hospital scenarios, the patient is always taking part in this telenursing service voluntarily and can exit
the encounter at any time. They are free to hang up the phone whenever they wish. This means that the
nurse needs to carefully negotiate how forcefully she guides the encounter.
A nurse explained that in order to get the information that was needed to reach a disposition, it was
sometimes necessary to take charge by interrupting the patient. She further elaborated on how she has
learned to direct patients:
I used to say, “oh, excuse me, ah, ah…” – and they would just, kind of, keep going on. So I really needed
to interrupt them and I do interrupt people now. I do definitely get what they call “call control”. So I
just keep interrupting and saying, “I need to stop you there, now” - by using a clear, I guess, direct
voice. Which still sounds caring.
Here the nurse describes the need to be assertive while still coming across as caring. The interruption in the
statement above was also evident on the recorded call we listed to. We noted however that each time the
nurse redirected the patient through statements like “I need to stop you there”, the patient was given a new
opportunity to offer input that was more relevant to the nurse’s efforts to triage the patient.
The duality that is being balanced here is a kind of distance that can be best understood through the
metaphor of grip. If the nurse grips the flow of the situation too tightly, by exerting too much control over
what is disclosed, the patient will not have enough room to express themselves, in order to share their
predicament. However, if the nurse is too relaxed in their direction of the situation, the patient would
reportedly offer irrelevant information that could get in the way of effective care. In some ways, the DSS
questions assisted the nurse in controlling the situation, however we were told the way in which some
scripted questions were phrased could distract the patient or lead them off track. The nurse therefore
translated the prompts into more nuanced questions, which enabled an appropriate, relevant flow of
information to emerge.
We conclude that in a telenursing encounter, the caller is the nurse’s “eyes and ears” (Aanestad, 2003, p.
18) and so they must feel appropriately free to speak willingly, while the nurse needs to direct the flow of
information. We thus argue that for two people to feel they are comfortably present with one another, these
intensities of freedom and control need to be balanced in response to the unfolding situation. In the
recorded call we listened to, the subtle and skillful way in which the flow of the encounter was negotiated
by the nurse was apparent. The nurse would carefully balance asking questions with showing concern for
the patient while giving them room to speak so they could express their own version of events and what was
important to them. At times, the way in which the nurse persisted with questions prompted by the DSS
could seem somewhat brusque, but it kept the situation on track and made it possible for the nurse to
become a caring presence for the patient.
In the following section we will show how our theorizing, brought about by the problematization of presence
inspired by our case and alternative conceptual material, enabled us to derive a model that shows the
dualities of presencing work as a balancing of nearness/farness and freedom/control. While analytically
separable the model demonstrates how these dualities are fundamentally linked in practice.

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A Model of Presencing Work
The conceptual model shown in Figure 1 is the result of our abductive process (Dubois & Gadde, 2014)
whereby our empirical case prompted a problematization (Alvesson & Sandberg, 2011) of the assumptions
that have guided our initial understanding of the concept of presence. In responding to this
problematization, alternative theoretical ground was laid that informed the theoretical insights outlined in
the previous section. Our insights are captured in the notion of presencing work, which we conceptualize
as involving the balancing of two dualities of distance: Nearness/Farness and Freedom/Control. We now
visualize these dualities as fundamentally connected. In doing so our model illustrates how presence is a
skillful, relational activity that fundamentally requires involvement with another and ongoing balancing
efforts.
Figure 1 – The Dualities of Presencing Work
Within this model of the dualities of presencing work, we further argue that presence does not stand in a
straightforward binary relationship to absence. Rather, it is possible to enact different modes of presence.
The ideal mode of presence is depicted at the center of the two dualities as a caring presence. We depict
alternate modes of presence as showing up in the relational experiences of autonomy, dependence,
domination, and neglect. The divergent quadrants show the modes of presence that are enacted when
balance is not maintained. We do not intend to imply that these quadrants are “bad” in any normative sense
but rather that they are shades of what may be experienced in the inevitable and necessary adjustments
involved in presencing work. We now explain these quadrants briefly with empirical illustrations motivated
by the nursing case.
Autonomy
Where nearness is established in a relationship, for example through shared history and empathy, and
where interactions offer freedom of choice, the relationship tends towards one of autonomy, where
presence is backgrounded. In the nursing case, this would mean the patient is left to cope with situation
without the guidance of the nurse. The patient may feel empowered but also frustrated, because they are
left without expert attention and need to make decisions about their care themselves.

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Dependence
Where nearness is enacted and control is exerted, a relationship tends towards dependence. In this scenario
there is an intimacy between the two parties but one party is dependent on the other for direction. This
involves a sense of excessive presence that may be overwhelming. For example, a patient might feel that
they are being talked down to and patronized; treated like a child, and with little sense of how they might
cope without the nurse.
Domination
Where a farness is exerted – a sense of separation but also control is maintained, presence appears in the
form of domination. This is a regulatory influence that may be felt as an acute, oppressive presence. One
party keeps the other at arm’s length, and yet their presence exerts a defining influence on the other’s
activities. This may come about for example if a nurse pressures the caller in order to get the call finished
as quickly as possible. The patient feels brusquely dealt with and does not have room to ask questions or
express themselves fully. The patient may feel bullied or ill-treated.
Neglect
When one party is involved with another but maintains a strong sense of separation while the other is also
given complete freedom, presence is experienced as a kind of absence understood as neglect. In taking no
responsibility for the other while enacting a farness, this form of presence is palpable in its absence. This is
a form of presence because it stands against an involvement – one party is important to another but is not
with them in an existential sense. In the nursing case this would translate into a kind of non-performance,
as operating in a way that shows disinterest towards the patient, which would likely result in the nurse’s
dismissal.
On distributed presencing work
The four quadrants in our model describe different modes of presence that are balanced in the course of
presencing work. In remote work, technologies are involved in this balancing process. They become
“equipment” (Riemer & Johnston, 2014; Sandberg & Dall'Alba, 2009) with which and through which
presence is achieved, maintained and negotiated. The degree to which this is successful in comparison with
co-located engagements depends largely on how skillfully presencing work is enacted – it is therefore in
this model not practical to explain which technologies will create presence, rather the model is meant to
assist in the exploration of how practitioners perform presencing work with and through the technologies
that have become part of their shared practice.
We point out that what we call presencing work is largely taken-for-granted in co-located practice, to the
extent that the efforts and equipment involved in these activities and negotiations may not be noticed at all
(uniforms, bodily contact, shift changes, monitoring schedules, etc.). The telenursing example however
provided grounds from which to see how these activities are translating into other contexts, and this new
context has, we argue, highlighted the dualities of distance as being both conceptually and practically
significant. We have argued that presencing work involves a balancing act of dualities, so that when the
dualities are out of balance, the results tend towards more extreme modes of presence. It is therefore the
negotiation of these dualities in response to the unique situation, according to one’s involvement in it, which
exemplifies the skill of presencing work.
Conclusion
We have problematized dominant conceptualizations of presence by focusing on an empirical case of
telenursing, which can be thought of as a “hybrid” of two empirical contexts: nursing and distributed work.
We have approached this problematization of presence through abductive case study research. We began
by outlining how presence is commonly understood in nursing and IS literature. This theoretical
background informed our “reading” of the case, in that certain incongruences between received wisdom
and the case material stood out to us as surprising. In particular, we noted that past experience and the role
of the body were important for the enactment of presence, and that technology was necessary but not

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sufficient for the nurse to become present with her patient, contrary to what some IS literature stipulates.
In particular, these findings counter traditional understandings of presence as being either necessarily co-
located or as being created by technology.
In response to these surprising findings, we returned to the conceptual basis of presence in nursing. By
looking more deeply at this literature, we found that in an existential philosophical orientation, distance is
treated not as a geographic fact but as something that is negotiated in our involvement with others and the
world from an embodied stance. This new conceptual understanding allowed us to derive novel insights
from our case, which we have expressed in the form of a model of the dualities of presencing work. In this
model, we firstly show that there are different “modes” of presence and that being a “caring presence” for
another is achievable in a distributed context, but it requires skill gained through experience as well as
ongoing work. Secondly we demonstrate that “presence” is not a condition for work to be ascertained a
priori but an integral part of work and thus inherently characteristic of the practice of telenursing. Our
model, findings, and the research process contribute to HISR, IS theory, and IS research practice in the
following ways.
To the field of HISR we contribute a model of presencing work, which we developed by drawing on both IS
and health literature in an effort to “push the contextual envelope” (Chiasson & Davidson, 2004). We
suggest that this model advances our appreciation and understanding of the skillful, embodied work that
goes into becoming a caring presence for patients in remote healthcare environments. This model further
adds nuance to current understandings of presence, because it highlights five modes of presence that a
practitioner can enact. This contribution problematizes the dominant binary model, which places presence
on one side of a dichotomy against absence. The contribution is significant because it offers potential insight
to practitioners who are reflecting on their caring practice, and also to researchers who are interested in
further studying how skillful balancing of the dualities of distance can be learned and enacted with
technologies in various healthcare settings, which occupy different positions on the co-located/distributed
continuum.
To IS theory we contribute a more nuanced understanding of technology-mediated presence. We argue that
presence in distributed settings requires technology, but is not created by technology. This contribution
takes the form of a provocation to the commonly held assumption that presence is best achieved in a co-
located, face-to-face setting. We locate this assumption in literature that seeks to replicate face-to-face
interaction through the use of technologies that create an “illusion” of co-location by surreptitiously
splitting mind and body. By reframing presence as an active, relational involvement, we shift the IS research
and design focus away from a replication of certain physical arrangements and towards thinking about how
technology becomes equipment (Riemer & Johnston, 2014) for presencing work where it constitutes and
supports skillful work practices that bring about presence as a by-product.
Finally, to IS research practice we contribute an illustration of an abductive case study method. In
presenting our research as a critical dialogue between a range of theoretical material and an empirical case,
we have embraced the kind of hybridity that a context such as telehealth requires. In the way we have
structured our paper, we show how extant literature can be held up to case material, where what is revealed
is the assumptions that have underpinned current understandings of a particular concept. We then model
how alternative conceptual material can be drawn on to respond to the surprising case findings, a partnering
that is subsequently used to generate novel insights. In our particular case, these insights were synthesized
into a conceptual model that offers a new way of thinking about the problematized concept of presence in
distributed work. We therefore show how this non-linear research approach both deconstructs and
constructs, and that this rebuilding can shed new light on concepts that are being increasingly challenged
by technologically-infused research environments.
Our insights become relevant against the growing trend of increasingly distributed and flexible working
arrangements, enabled and supported by technology. We contend that our model of presencing work is
relevant to researchers who are interested in better understanding how caring relationships are maintained
in this broader context of ICT-enabled remote work. For example, the presencing work efforts that we have
conceptualized in the context of nursing practice may also translate to managerial relationships in
distributed organizations. While the nuances of activities involved in balancing the dualities of distance will
have to be contextually framed, we suggest that our model offers a starting point for further exploration
into the intricacies of presencing work, in a range of organizational settings.

Negotiating Distance: “Presencing Work” in Telenursing
Thirty Seventh International Conference on Information Systems, Dublin 2016 18
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